Role of Ten Precontouring in Paediatric Diaphyseal Forearm Fracture Fixation: From Research to Clinical Practice

The growing incidence of paediatric both bone fractures and the increased tendency for operative treatment using the titanium elastic nailing (TEN) technique has been established in the literature. We aim to evaluate the importance of titanium elastic nail pre-contouring on radiographic and clinical outcome in AO PCCF 22-D/4 and D/5 fractures. Cohort I- twelve cadaveric forearms (six pairs) were divided into 3 groups of six specimens: Group 1 – Two straight nails; Group 2 – 1 curved and 1 straight nail; Group 3 – Two curved nails. The same forearm specimen was used for group 1 and group 2 by exchange of the radial nail only. In Cohort II, 80 patients who underwent elastic nailing were followed up for a mean period of 17.9 months. Maximal radial bow (MRB), location of MRB and MRB as percentage of radial length were measured on the AP x-rays. Outcome for Cohort II was evaluated using QuickDASH and range of motion (ROM) testing at the time of implant removal. When compared between each other, instrumented groups in Cohort I showed statistically significant difference in MRB (P= .000), %MRB (P= .000) and LMRB (P= .000). Compared to the intact forearms: Group 1 showed decrease in MRB of 3.7mm (P= .003), decrease in %MRB of 1.85%, increase in LMRB of 2.64% (P=. 459); Group 2 showed increase in MRB of 1.9mm, increase in %MRB of .93%, decrease in LMRB of 1.8%; Group 3 showed increase in MRB of .73mm (P= .073), increase in %MRB of .36%, decrease in LMRB of 2.01% (P= .27). In Cohort II patients with loss of prono-supination (n=8) had a mean value of LMRB of 72.45, compared to 63.5 for those without loss in range of motion (n=72), which was statistically significant (P= .003). Mean QuickDASH score and loss of forearm rotation in the ROM impaired group were 6.75 and 11° respectively. Cadaveric experimentation shows that the use of two titanium elastic nails of identical size and bend assures the best possible reduction. Fixation via 1 curved and 1 straight implant leads to slight overcorrection of the radial bow whereas utilization of 2 straight TENs leads to the worst radiographic results. Clinical evidence correlates with cadaveric results, as all patients with loss in range of motion in our series had an increase in LMRB values, which may suggest suboptimal implant contouring.